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Utah Arthritis Program Strategic Plan

Business overview and sustainability plan for evidence-based chronic disease self management education programs in Utah

December 2015

Utah Arthritis Program

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Table of Contents

Acknowledgments.......................................................................................... IIExecutive Summary........................................................................................ 1Introduction.................................................................................................... 2 Business Description...................................................................................... 4 Reach and Scope............................................................................................. 8Program Delivery Infrastructure..................................................................... 10Business Development................................................................................... 16Future steps.................................................................................................... 23 Conclusion...................................................................................................... 28Appendices..................................................................................................... 29

Appendix A: Prevalence of Arthritis in Utah............................................ 29Appendix B: Active Implementation Partners........................................... 31

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Acknowledgments

Appreciation is extended to Keegan McCaffrey, BA, Health Program Specialist, Utah Arthritis Program, who wrote this report.

We also express our appreciation to the following individuals for editing this report:• Rebecca Castleton, BS, CHES• Randy Tanner, MPA• Celsa Bowman, MS• Jenny Johnson, MPH

The Utah Arthritis Program also acknowledges the following individuals for their support in producing this report:

• Rebecca Castleton, BS, CHES, Program Manager, Utah Arthritis Program • Randy Tanner, MPA, Epidemiologist/Evaluator, Utah Arthritis Program• Britney Brown, MPH, Epidemiologist/Evaluator, EPICC Program• Christine Weiss, MPH, CHES, Former Utah Arthritis Program Member• Heather Borski, MPH, CHES, Director, Bureau of Health Promotion

Funding for this publication was provided by the U.S. Administration for Community Living, Administration on Aging (AOA; HHS-2015-ACL-AOA-CS-0094), and the U.S Centers for Disease Control and Prevention (CDC; CDC-RFA-DP12-1210). The contents of this report are solely the responsibility of the Utah Arthritis Program (UAP) and do not represent the opinions of the CDC or the Administration on Aging.

For more information contact:Utah Department of HealthBureau of Health PromotionUtah Arthritis ProgramPO Box 142107Salt Lake City, Utah 84114-2107Phone (801) 538-9193 [email protected]://health.utah.gov/arthritis

1Executive Sum

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Executive Summary

The Utah Arthritis Program (UAP) has worked for the past sixteen years to improve the quality of life for people affected by arthritis across Utah. Over the past nine years, the UAP has allocated federal funds to build, support, and grow delivery system partners and a statewide infrastructure to implement Stanford University’s Chronic Disease and Diabetes Self-Management Programs, locally called Living Well with Chronic Conditions and Living Well with Diabetes.

As federal funding continues to decrease, the UAP is exploring means to achieve long-term sustainability. This document presents a detailed overview of the UAP as an organization and two plausible future scenarios to achieve this goal. The first scenario addresses sustainability measures and future steps in the case of reduced funding, whereas the second scenario outlines future activities and responsibilities if the UAP is able to maintain a similar level of funding as it does today. Additionally, this strategic plan addresses the future financial needs of the UAP and its implementation partners. It also describes the UAP’s Living Well programs; vision, mission, and goals; internal and external implementation partner network; and efforts in technical assistance, data collection, and reach expansion. Our plan is informed through a statewide collaboration on sustainability with our partners, and a review of financial independence efforts being implemented in other states.

The UAP is well positioned to continue improving both the quality of life and the health outcomes of Utahns with chronic conditions. This will best be accomplished with the benefit of a reliable strategic plan and continued coordination with our statewide partners.

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Introduction

The purpose of this strategic plan is to provide an outline towards programmatic sustainability for the Utah Arthritis Program, and its implementation network of evidence-based self-management programs in Utah. Specifically, we focus on guiding efforts for Stanford’s Chronic Disease Self-Management Education programs (CDSME), known locally as Living Well with Chronic Conditions. In planning the future of these programs we will explore the fiscal and implementation needs of the program while determining the most feasible path to embed self-management workshops in healthcare and community organizations as a standard practice for treating chronic conditions.

Living Well workshops are offered across the state through a network of over 20 partners coordinated through the UAP within the Utah Department of Health (UDOH). This network of partners includes local community non-profits, area agencies on aging, local health departments, and healthcare systems. Financial support for these organization’s CDSME implementation efforts has been in large part provided by the reallocation of federal grants from the Centers for Disease Control and Prevention (CDC) and the Administration on Aging (AoA). However, with federal support waning and the current grant periods coming to a close, it is time to plan for alternative funding mechanisms and move towards sustainability. Fortunately, our strategic plan coincides with both a cultural and policy shift in the way healthcare is offered, funded, and evaluated. In 2010, 86 percent of national healthcare dollars were spent by people with one or more chronic conditions1. As such, both private and public insurance providers and healthcare systems are exploring options to reduce the costly burden of chronic diseases by focusing on prevention and education to improve health outcomes and promote self-management as a powerful cost reduction tool.

1. Gerteis, Jessie; Izrael, David; Deitz, Deborah; LeRoy, Lisa; Ricciardi, Richard; Miller, Therese; Basu, J. (2010). Multiple Chronic Conditions Chartbook 2010 Medical Expenditure Panel Survey Data. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-care/ decision/mcc/mccchartbook.pdf

3Introduction

Introduction

Methodology and Goals

This initial version of the UAP Strategic Plan was developed through extensive meetings between UAP staff members, internal and external partners, and a review of seven of our implementation partners’ sustainability plans. This plan was also influenced by the business plans developed by Oregon and Missouri. The goal of this version of our strategic plan (December 2015) is to act as a conversation starter for Living Well stakeholders in Utah to discuss and plan for a sustainable future. In January 2016, the UAP will share this plan with our Living Well Coalition (LWC) and use the feedback to revise and finalize the document.

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Problem Description

Seven of the top ten causes of death in the US are caused by chronic disease1. In Utah, nearly six in ten Utah adults have at least one chronic condition2 and the healthcare costs associated with chronic disease exceed $586 million3. These conditions, and their respective societal burdens, are also not mutually exclusive. Obesity, diabetes, high blood pressure, arthritis and many other conditions are underscored by unhealthy behaviors, namely lack of exercise or physical activity, poor nutrition, tobacco use, and excessive drinking. Lessening the burden of chronic disease is a major challenge facing public health. By educating those with chronic conditions to better manage their physical and emotional symptoms and engage in healthy behaviors, we can improve the quality of countless lives and prompt better utilization of healthcare resources.

Core Product Description

Living Well, or the Chronic Disease Self-Management Program, was developed and researched for over 20 years at Stanford University School of Medicine in collaboration with Kaiser Permanente. The six-session weekly workshop is based on a model where two leaders, one or both of whom has a chronic condition, co-facilitate each class. Groups of 10-15 participants meet 2-2.5 hours each week to share and learn from one another, provide peer support, and learn proven self-management skills. Together the group learns and practices self-management skills such as:

• Managing frustration, fatigue, pain and isolation• Exercise and diet to maintain and improve heath • Appropriate use of medications and proper nutrition• Communicating effectively with family, friends, and health professionals• Evaluating new treatments• Setting goals

Business Description

1. Centers for Disease Control and Prevention. Death and Mortality. NCHS FastStats Web site. http://www.cdc.gov/ nchs/fastats/deaths.htm. Accessed December 21, 2015.2. Utah BRFSS 2007, 20093. 2010 Utah All Payer Claims Database

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Core Product Description

The Living Well Program is held at various community settings such as clinics, hospitals, community centers, senior centers, and churches across Utah. Workshops are also offered in a variety of languages including Spanish (branded as Tomando Control de su Salud), Tongan, Samoan, and Navajo.

Created by Stanford and supported by the Centers for Disease Control (CDC), the outcomes of completing Living Well workshop have been extensively studied. A recent meta-analysis highlighted that Living Well participants had long term (measured 9-12 months post workshop) improvements in both aerobic and stretching/strengthening exercise, cognitive symptom management, and multiple measures of psychological health1. Additionally, these benefits in patient wellbeing have economic benefits. Although the magnitude varies between studies, most agree that Living Well significantly reduces sick days and improves healthcare utilization1,2. In fact, a 2001 study by Lorig et al.3 conservatively estimated a two-year return on investment (ROI) of $390 - $520 per participant from reduction in hospitalizations and out-patient visits.

1. Brady, T. J., Murphy, L., O’Colmain, B. J., Beauchesne, D., Daniels, B., Greenberg, M., … Chervin, D. (2013). A meta-analysis of health status, health behaviors, and healthcare utilization outcomes of the Chronic Disease Self-Management Program. Preventing Chronic Disease, 10(1), 120112. http://doi.org/10.5888/pcd10.1201122. Gordon, C., & Galloway, T. (2008). Review of Findings on Chronic Disease Self- Management Program (CDSMP ) Outcomes : Evidenced-Based Healthy Aging Program, 1–10. http://patienteducation. stanford.edu/research/Review_Findings_CDSMP_Outcomes1%208%2008.pdf3. Lorig, K. R., Ritter, P., Stewart, a L., Sobel, D. S., Brown, B. W., Bandura, a, … Holman, H. R. (2001). Chronic disease self-management program: 2-year health status and health care utilization out comes. Medical Care, 39(11), 1217–1223. http://doi.org/10.1097/00005650-200111000-00008

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Utah Arthritis Program Overview

Vision: To increase self-management skills and improve the quality of life for all Utahns affected by arthritis and other chronic conditions.

Mission: To build a sustainable, recognizable, and widely accessible delivery system for evidence-based chronic disease self-management programs in the state of Utah. The UAP develops and maintains this delivery system by providing technical assistance and coordination for a network of implementation partners.

Goals and objectives: • Foster and develop a state-wide coalition of partners to implement CDSME

classes • Provide reliable information and marketing materials to improve the perception of

self-management workshops • Encourage self-management techniques as a regular course of treatment for

chronic diseases

UAP History The UAP, was created in 1999 to improve the quality of life for people affected by arthritis. The UAP has been funded federally since its inception, and is currently one of only 12 states receiving funds from the CDC. In 2010, the UAP received additional funding through the AOA. With these funds, the UAP has developed a system of partners to deliver self-management classes by allocating financial grants, ensuring statewide licensing and fidelity, program marketing, and providing technical assistance and coordination.

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Utah Arthritis Program Overview

The evidence-based self-management programs currently offered across our network of partners include:

• Living Well with Chronic Conditions (Stanford’s Chronic Disease Self-management Program, (CDSMP)

• Walk With Ease (WWE)• Enhance Fitness (EF)• Arthritis Foundation Exercise Program (AFEP)• Living Well With Diabetes (Stanford’s Diabetes Self-Management Program,

(DSMP)

ServicesThe UAP is the coordination center for the evidence-based classes listed above. We pro-vide a range of services including:

Niche The UAP is the only organization that offers centralized, statewide licensing, coordination, and technical support for Living Well workshops in Utah. Research supports that Living Well both improves health outcomes and reduces the burden on healthcare systems. As an entity of the State Health Department, the UAP is uniquely positioned to recruit and retain partnerships with local governments, area agencies on aging, healthcare systems, and private organizations. By acting as a focal point for coordination across Utah, the UAP uses a progressive approach to growing programs and ensuring consistent delivery, maximizing returns, reach, and recognition for the program as a whole.

• State-Wide Licensing• Quality assurance • Technical support for implementing classes• A web based data management tool (Partner Portal)

• Data collection and analysis• Coordinated scheduling• Marketing and public relations• Outreach and partner development• Peer-leader training

8

From September 2008 through December 2015, 7,205 participants have attended the Living Well workshops. Workshops have been provided through the efforts of 28 host organizations at 305 unique locations throughout Utah. Workshops have been conducted in 25 of Utah’s 29 counties but most have been conducted along the Wasatch Front, where the majority of Utah’s population resides.

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2008 2009 2010 2011 2012 2013 2014 2015

Number of CDSME Workshops

CDSMP DSMP Spanish CDSMP Spanish DSMP

Figure 1

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2008 2009 2010 2011 2012 2013 2014 2015

Number of CDSPE Participants

CDSMP DSMP Spanish CDSMP Spanish DSMP

Figure 2

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Non-completers Completers

9Reach and Scope

Reach and Scope

Figure 3: Completers vs non-completers, out of N=6448 participants. A “Completer” is considered a participant who attends 4 or more of the 6 workshop sessions:

Figure 4: Number of participants per local health district for FY 2014 - 2015

Weber-Morgan 238

Davis 152

Southeastern134

Southwest211

Tooele58

Utah214

TriCounty29

Central88

Summit40

Wasatch8

Bear River124

Salt Lake County 1696

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Program Delivery Infrastructure

The UAP operates as centralized state funded organization. The program recruits and establishes a network of partners to deliver programs across a geographical area. Currently, the UAP oversees a delivery system of over 20 implementation partners, 16 of which are funded in part through UAP mini-grants. In addition to providing funding, the UAP offers technical assistance and regulation for implementing Living Well, collects and analyzes data, and drives programmatic growth across Utah. UAP staff, therefore, need to be experienced health educators, communicators, project managers, and public health advocates to ensure delivery capacity, identify and develop new partners and funding resources, and communicate the benefits of implementing Living Well.

Implementation Partner Network Every partner joining the UAP’s delivery network enters into an agreement with the UAP to follow implementation protocols in return for receiving UAP support. After being selected, funded partners enter into a clearly defined contract outlining responsibilities like program quality assurance measures, data management requirements, and funding limits. Below is a breakdown of responsibilities between partners and the UAP.

11Program

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Management and staff The UAP falls under the UDOH leadership structure. Dr. Joseph Miner is the Executive Director for the UDOH. Dr. Robert Rolfs is the Deputy Director over the Division of Disease Control and Prevention which is managed by Jennifer Brown who oversees the operations of the Bureau of Health Promotion. Heather Borski directs the operations of the Bureau of Health Promotion within which the UAP is located. The UAP is managed by Rebecca Castleton.

Key staff

Rebecca Castleton, BS, CHESProgram ManagerRebecca Castleton has been in the UAP since November 2008. She administers the arthritis self-management interventions throughout the state through program planning, implementation, and evaluation. She is involved with public outreach and building partnerships with other agencies to increase awareness of and participation in arthritis-related and chronic disease self-management programs. Rebecca received a Bachelor of Science degree in Public Health from Brigham Young University and was CHES certified in 2009. She brings experience in infant mortality program services, nation-wide research on reduced tobacco use in Russia, and international micro-business and health education experience in El Salvador.

Figure 5: Utah Arthritis Program Organizational Chart

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Key staff

OpenProgram SpecialistThis position’s duties include public outreach and building partnerships to increase awareness and participation in arthritis related programs. This person helps with the planning, implementation, and evaluation of a variety of evidence-based arthritis exercise and self-management programs. Additionally, they will manage media and public relations.

Randy Tanner, MPAEpidemiologist/Evaluation Specialist Randy is the UAP Epidemiologist/Evaluation Specialist and has been with the UDOH for over 35 years. Randy earned a Masters of Public Administration from Brigham Young University and a Bachelor’s of Science degree in Health Education from the University of Utah. As an epidemiologist his primary responsibility is to develop an arthritis surveillance system and evaluate the effectiveness of the UAP. He is also responsible for analyzing data to determine the prevalence of arthritis in Utah, medical costs associated with arthritis, quality of life for Utahns with arthritis, and self-management practices of people with arthritis.

Keegan McCaffrey, BAHealth Program SpecialistKeegan McCaffrey is a temporary two-year employee assigned to the UAP from the CDC Public Health Associate Program. He has assumed many of the Health Program Specialist’s roles, working towards the implementation and sustainability of evidence-based chronic disease self-management programs. Keegan also oversees media, public relations, and Living Well peer leader training. He has a Bachelor’s of Arts and Sciences from the University of Colorado and has experience in program planning and evaluation, West Nile Virus prevention, and disease ecology research.

13Program

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Current funding and costsUAP Financials

Fiscal year 2016 ushers the UAP into a period of transition for programmatic funding. Thus far, the UAP and subsequent partners have been funded through a variety of federal sources which have included grants from the CDC and the AOA. Between these two sources the UAP was funded at a $598,231 for FY 2015. However, due to the conclusion of the AoA great period and incremental cuts to the CDC grant, funding for FY 2016 is $332,308 (see Figure 6 left).

Utah Arthritis ProgramUtah Health Department

FY 2016 BudgetREVENUESCDC Grant 4261 332,308.00 SUBTOTAL 332,308.00

EXPENSESPersonnel (193,267.00)Contracts (120,150.00)Travel (1,863.00)Operations (17,164.00)Licensing (3yr) - SUBTOTAL (332,444.00)

TOTAL (136.00)

Living Well Workshop Expenses:

Workshop expenses vary widely between partners. First, staff time and associated costs, the use of volunteer leaders, materials, and annual number of classes all impact the costs of providing a workshop. Statewide, the UAP estimates the cost of implementing a workshop to be roughly $225 per participant, amounting to roughly $2,500-$3,000 a workshop. For FY16, The UAP provides grants on a per-participant basis, paying $100 for participants who attended 4 or more classes, and $25 for participants who attend 3 or fewer classes. The discrepancy between estimated and paid values reflect both cuts in UAP funding and a push towards promoting partner sustainability.

No two partners have the same amount institutional support. For example, some local Area Agencies on Aging are able to use Title III D funding to supplement workshop expenses, while others, like healthcare providers, are able to supply staff time to plan and lead workshops. Likewise, rural areas tend to incur larger costs because of the expenses incurred for traveling to and recruiting class participants.

Marketing

Because the UAP offers a service to healthcare providers, there are three equally important markets that need to be targeted to ensure long-term programmatic viability: participants, referral partners, and healthcare payers.

When advertising Living Well workshops, the UAP relies on implementation partners to market to and recruit participants. This gives our local implementers the ability to balance workshop supply with participant demand and leverage their unique connection and understanding of their respective communities. The UAP therefore focuses on creating and marketing statewide systems to expand reach and recruit participants. In an ideal future, Utahns diagnosed with chronic conditions will be referred to workshops by a clinic that can then follow up with the participants as they complete the workshops to evaluate their outcomes. To make this vision a reality, the UAP is currently building a website to serve as a one-stop-shop for locating evidence-based self-management programs. The website, livingwell.utah.gov, is being developed in conjunction with other programs in the Bureau of Health Promotion and will function as a referral and registration tool for participants and providers. To bring providers to the website and ensure broad programmatic recognition, the UAP also meets and provides conferences with healthcare providers, advertising Living Well as mutually beneficial for patients and providers.

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What WhoParticipants Utah adults with chronic conditions

and their families/caregivers

Referral Partners Physicians, Clinics, Hospitals, healthcare managers, healthcare qual-ity assurance groups

Healthcare Payers Insurers, large employers,Medicare, Medicaid

Figure 7: Target Population

15Program

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Marketing The UAP’s other marketing efforts include a yearly marketing campaign to raise general awareness on arthritis and other chronic conditions, media and public relations to promote Living Well, and developing coordinated branding and marketing materials. All marketing efforts focus on delivering the message that Living Well:

• Improves patient outcomes and minimizes sick days• Teaches proper healthcare utilization• Is evidence-based and delivers verifiable results• Improves quality assurance evaluations as a way of moving towards value-based

care

Perhaps the most crucial aspect of marketing Living Well and the UAP is to connect with healthcare payers and ensure buy-in. In Utah alone, an estimated 17.7 percent of the population has been diagnosed with two or more chronic conditions (2014 BRFFS), and the combined cost of treatment for chronic conditions is well over half a billion dollars (Utah All Payer Claims Database, 2009). Because of the exorbitant expenses involved with treating chronic conditions, healthcare payers (e.g. insurers, large employers, Medicare and Medicaid) have the most economic incentive to offer self-management programs. UAP efforts for reaching out to this relatively small but extremely important group of institutions are mostly focused through personal contact with staff. Strategies for these communications include:

• Leveraging partnerships and internal connections for initial contact and to set up meetings

• Having data readily available on Utah specific health outcomes• Working with HealthInsight to promote Living Well and EBP’s• Communicating that Living Well offers a solid ROI• Setting up pilot workshops to ensure the program and structure are meeting both

the UAP and healthcare payer expectations

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Business Development

Overview

As of January 2016, the UAP will be moving into a period of transition. Much of the initial infrastructure necessary to create a sustainable and broad reaching delivery network is already in place and running smoothly. However, with the end of our CDC grant on June 30, 2017, and no funding sources readily available, the UAP finds itself in the position of deciding between what is preferred and what is most practical for the future. To reflect this dichotomy, the planning section of this report will contain two different scenarios: the practical reduced funding, decentralized development and the preferred high funding, centralized development. It is important to note that both of these plans aim to achieve the same goal: build a sustainable, recognizable, and widely accessible delivery system for evidence-based chronic disease self-managements programs in the state of Utah. They do, however, differ in the time line and role of the UAP to achieve program sustainability.

Scenario One: Reduced Investment, Decentralized Development

The best case scenario for long-term funding and sustainability for Living Well and other chronic disease self-management programs across Utah requires further investment in the UAP to maintain reach and centralized coordination. However, preferred plans are not necessarily the most feasible, and, given the current trends in government funding, we feel it necessary to plan and act on a course to sustainability after 2017 if the UAP is unable to secure major additional funding. This scenario, therefore, depends on the robust internal and external partnerships that the UAP has nurtured over its 15 plus year history, along leveraging recent gains made in healthcare system buy-in and overlapping goals between self-management education providers across the state.

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Scenario One: Reduced Investment, Decentralized Development

For this scenario, the success of Living Well relies heavily on ensuring that most partners are implementing workshops on their own by the end of 2017. The UAP has already made great strides towards this, for example in the past year the UAP has:

• Required our current partners to develop sustainability plans • Worked with HealthInsight (the healthcare quality improvement organization

in Utah) to push Living Well programs in clinics as a way to meet their quality requirements

• Forged new partnerships with private insurers like Molina healthcare to fund its own classes in FY 2016

With these accomplishments in mind, the most likely long-term, sustainable funding sources include:

• Public and private insurance reimbursements• Medicare and Medicaid billing• Work place health and wellness plans• Embedding programs within healthcare providers and community based systems• Participant payment

Despite recent gains towards sustainability, implementing the above funding sources by mid-2017 will be no easy task, and unfortunately some partners serving smaller populations would likely have to reduce the number of workshops being delivered or stop implementing classes all together. This could also disproportionately affect rural and disparate populations, as implementing classes in those areas tends to be more expensive than in population dense locations. Also, losing the ability to maintain a statewide license would become an undue burden on workshop delivery, as they cost $500 for most small programs and $1000 for larger programs every three years. To help mitigate these changes, in the next two years the UAP will focus its effort to improve current partner sustainability, explore and develop insurance reimbursement and participant funded workshops, and expand partnerships with healthcare systems that are more able to continue implementation without state funds.

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Scenario One Services and Financial Requirements:

Without significant additional funding, the UAP would not have the resources to provide all of its previous services and would transition many of the day-to-day and logistical tasks to individual implementation partners. These include:

• Maintaining licenses and fidelity• Developing relationships with healthcare providers for participant referrals• Funding workshop delivery

Likewise, the leadership and coordination responsibilities would move under the Living Well Coalition (LWC), our collaborative steering committee comprised of Living Well implementation partners and stakeholders. The LWC would:

• Provide centralized coordination and leadership• Use member organization expertise to provide guidance and technical support to

new partners• Explore sustainable funding opportunities and partnerships• Plan and manage peer-leader trainings

Although the LWC would be able to take on many of the leadership roles currently performed by the state, we also see the necessity to retain some of UAP’s roles within the UDOH. Most likely funded and run through coordination with internal partners, these roles include:

• Collecting and analyzing workshop and program data• Maintaining the arthritis program website and the Partner Portal• Creation and management of a fair and systematic referral system for all partners

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Scenario One Services and Financial Requirements:

-

50,000.00

100,000.00

150,000.00

200,000.00

250,000.00

300,000.00

350,000.00

400,000.00

FY 16 FY 17 FY 18 FY 19 FY 20 FY 21

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USD

)

Utah Arthritis Program

Utah Department of Health

Scenario One Estimated Expenses

FY 16 FY 17 FY 18 FY 19 FY 20 FY 21

Prof Salaries (110,563.00) (112,774.26) (52,020.00) (53,060.40) (54,121.61) (55,204.04)

Prof Benefits (62,362.00) (63,609.24) (29,765.84) (30,361.16) (30,968.38) (31,587.75)

Contracts (128,005.00) (128,005.00) - - - -

Indirect (21,961.48) (22,400.70) (3,780.26) (3,855.87) (3,932.98) (4,011.64)

Operations (17,554.00) (17,905.08) (4,946.00) (5,044.92) (5,145.82) (5,248.73)

Travel (1,863.00) (1,900.26) (931.86) (950.50) (969.51) (988.90)

Web (Partner

Portal) - - (3,000.00) (3,000.00) (3,000.00) (3,000.00)

Licensing - (2,667.00) - - - -

TOTAL (342,308.48) (349,261.54) (94,443.96) (96,272.84) (98,138.30) (100,041.07)

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Scenario Two: High Investment, Centralized Development:

This scenario is based around the UAP retaining its current business model as a centralized public health delivery system. The continuation of the UAP’s central role in funding, developing, coordinating, licensing, quality assurance, and sustaining Living Well and other self-management classes statewide is contingent upon maintaining a comparable level of funding as we move through 2017. The benefits of this funding are enormous because it would allow for the centralized leadership and longer time frame necessary to develop systematic sustainability. With supporting grant funds, the UAP would be able to incrementally disconnect implementation partners from reliance on state funding, transitioning towards more reliable funding sources (e.g., Private and public insurance reimbursements and participant payment).

Prolonged UAP financial support for implementation partners is needed to maintain reach. While our most engaged partners have verbally committed to offering classes without state funding, it is important to note that even for large partners a single workshop can cost upwards of $1,000 to run, and they would likely need to reduce the number of classes offered. Because of this, we need more time to develop secure funding avenues and help create a more diversified funding model for Living Well and other evidence-based programs.

While this may be the best option for the UAP and its partners when it comes to long term sustainability, the viability of this plan is arduous. This plan is dependent upon the political and economic factors that determine federal and state funding. To assure that we succeed, the UAP will aggressively search out state, local, and federal grants, and continue to develop connections with non-profit and charitable organizations.

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Scenario Two Services and Financial Requirements:

In keeping with our current business model, the services provided by the UAP in scenario two would include:

As the UAP moves into the future we will also dramatically increase our current efforts to:

• Nurture relationships with private and public insurance companies and move toward a reimbursement for a value-based service model

• Work closely with healthcare providers to develop a bi-directional referral system and encourage healthcare system by-in for self-management education

• Focus on developing partners with the capacity to deliver programs without additional funding

• Test new funding models like participants paying to attend

To offer these services, significant funding would need to be secured through (a) governmental grants (b) state funding, or (c) large private donations. To continue to move towards partner sustainability, this plan proposes a 20 percent decrease per year in workshop implementation funding to our partners. This allows the UAP to move self-sustaining partners off of state funds while still allowing time to further develop funding opportunities for partners in rural areas and those serving disparate populations. Also, by reducing the number of contracts, the UAP can use more resources in pursuing insurers and getting buy-in from healthcare providers. Below is a six year break down of anticipated costs to maintain this business model.

• State-Wide Licensing• Quality assurance • Technical support for implementing

classes• A web based data management tool

(Partner Portal)

• Data collection and analysis• Coordinated scheduling• Marketing and public relations• Outreach and partner development• Peer-leader training

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Scenario Two Services and Financial Requirements:

-

50,000.00

100,000.00

150,000.00

200,000.00

250,000.00

300,000.00

350,000.00

400,000.00

FY 16 FY 17 FY 18 FY 19 FY 20 FY 21

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Utah Arthritis ProgramUtah Department of Health

Scenario Two Estimated Expenses

FY 16 FY 17 FY 18 FY 19 FY 20 FY 21

Prof Salaries (110,563.00) (112,774.26) (115,029.75) (117,330.34) (119,676.95) (122,070.49)

Prof Benefits (62,362.00) (63,609.24) (64,881.42) (66,179.05) (67,502.63) (68,852.69)

Contracts (128,005.00) (128,005.00) (102,404.00) (81,923.20) (65,538.56) (52,430.85)

Indirect (21,961.48) (22,400.70) (22,848.72) (23,305.69) (23,771.81) (24,247.24)

Operations (17,554.00) (17,905.08) (18,263.18) (18,628.45) (19,001.01) (19,381.03)

Travel (1,863.00) (1,900.26) (1,938.27) (1,977.03) (2,016.57) (2,056.90)

Web (Partner

Portal) - - (3,000.00) (3,000.00) (3,000.00) (3,000.00)

Licensing - (2,667.00) (2,667.00) (2,667.00) (2,667.00) (2,667.00)

TOTAL (342,308.48) (349,261.54) (331,032.34) (315,010.76) (303,174.53) (294,706.20)

23Future steps

Future steps

Overview Below is a list of future steps and milestones for the UAP through fiscal year 2020. The steps for fiscal years 2017 – 2020 are further divided by scenarios one and two described above, depending on the level of funding and support the UAP is maintain after the completion of our current CDC grant in FY 2017.

FY16 (July 2015-June 2016)• Implementation Partners

○ Share completed strategic plan with stakeholders, (make necessary revisions) ○ Provide guidance and ensure partner sustainability plan goals are being met ○ Continue expanding reach with contracts to fulfill current CDC obligations ○ Work with HealthInsight to collect, analyze, and present data on participant

health outcomes ○ Promote and enhance the Living Well Coalition’s role in state leadership and

coordination• Funding

○ Secure at least one insurer to reimburse a workshop(s) ○ Explore at least one workshop paid for by participants ○ Search for public and private funding opportunities ○ Continue conversations with Medicare Advantage plans for buy-in ○ Participant/workshop delivery infrastructure ○ Transition Partner Portal to Compass ○ Build bi-directional referral system website for providers to refer and track

clients through workshops ○ Host evidence-based program conference to educate healthcare providers on

UDOH programs ○ Update marketing materials to match new website

24Fu

ture

ste

ps

FY16 (July 2015-June 2016)• Participant/workshop delivery infrastructure

○ Transition Partner Portal to Compass ○ Build bi-directional referral system website for providers to refer and track

clients through workshops ○ Host evidence-based program conference to educate healthcare providers on

UDOH programs ○ Update marketing materials to match new website

Scenario One Future Steps (low investment, decentralized development)

FY17 (July 2016-June 2017)• Implementation Partners

○ Provide guidance and ensure partner sustainability plan goals are being met ○ Continue expanding reach with contracts to, fulfill current CDC obligations ○ Complete outcome studies and present findings to insurers and other

healthcare leaders ○ Transition main coordination activities to Living Well Coalition, ensure

current network of master trainers are communicating regularly ○ Create referral guidelines to minimize competition between implementation

partners ○ Begin transition of funding and licensing to individual partners

• Funding ○ Have regular reimbursed workshops, funded by more than two or more major

insurers ○ Apply for CDSME and other evidence-based programing focused public and

private grants ○ Ensure key UAP roles will continue to be covered within UDOH

• Work closely with The Healthy Living through Environment, Policy, and Improved Clinical Care Program (EPICC) and the Falls Prevention Program to leverage state resources

○ Continue to develop new self-sustaining partners within the healthcare system

Future steps

25Future steps

Scenario One Future Steps (low investment, decentralized development)

FY17 (July 2016-June 2017, continued)• Participants/workshop delivery infrastructure

○ Re-negotiate website and Compass (Partner Portal) contracts ○ Continue to market and evaluate referral website, make changes if necessary ○ Create new methods of coordinating and funding peer-leader trainings ○ Ensure fidelity can be meet by current network of master trainers

FY 18-20 (July 2017-June 2020)• Implementation Partners

○ Execute full transition of outlined roles from UAP to LWC and individual partners

○ Continue to seek out new self-sustaining implementation partners ○ Provide technical assistance and have partners re-evaluate their sustainability

plans ○ Partners recruit and retain funders directly ○ Disseminate successes and best practices between partners

• Funding ○ Seek out funding sources for the UAP and our partners ○ Leverage state resources to support EBP’s ○ Revisit Medicaid and Medicare application (annually)

• Participants/workshop delivery infrastructure ○ Grow participant base through referral systems and coordinated marketing ○ Maintain and expand online tools such as Compass (Partner Portal) ○ UAP, LWC and partners continually evaluate workshop demand, leader

trainings, and workshop coordination

Future steps

26Fu

ture

ste

ps

Future steps

Scenario Two Future Steps (high investment, centralized development)

FY 17 (July 2016-June 2017)• Implementation Partners

○ Provide guidance and ensure partner sustainability plans goals are being met ○ Continue to expand reach with contracts, fulfill current CDC obligations ○ Complete outcome studies, present findings to insurers and other healthcare

thought leaders ○ Begin partner re-evaluation and create three-year funding plans to slowly

decrease state funding• Include specific sustainability milestones within new contracts to give

the UAP ability to monitor and evaluate partners progress towards sustainability

• Funding ○ Have regular reimbursed workshops, funded by more than two or more major

insurers, provide economic incentive for partners to develop ulterior funding ○ Apply for, and in this scenario receive, major chronic disease self-

management grants ○ Ensure key UAP staff roles are filled and new re-evaluate staff roles for new

grant period• Work closely with EPICC and Falls to leverage state resources

○ Continue to develop new partners to expand reach • Focus on partners likely to become self-sustaining within three years and

those that reach disparate populations• Participants/workshop delivery infrastructure

○ Re-negotiate website and Compass contracts ○ Continue to market and evaluate referral website, make changes if necessary ○ UAP, LWC and partners continually evaluate workshop demand, leader


27Future steps

Future steps

Scenario Two Future Steps (high investment, centralized development)

FY 18-20 (July 2018 – June 2020)• Implementation Partners

○ Continue to seek out new self-sustaining implementation partners ○ Provide technical assistance and have partners re-evaluate individual

sustainability plans ○ Reduce or cut off funding for sustainable partners

• Funding ○ Continue to seek out funding sources for the UAP and partners

• Introduce new funders to implementation partners• By end of FY 19, two-thirds of workshops should be sustained through

external funding sources, without decreasing reach ○ Begin to explore franchise model if enough partners are cash-flow positive ○ Leverage state resources to support EBPs ○ Revisit Medicaid and Medicare application (annually)

• Participants/ workshop delivery infrastructure ○ Continue to increase participant base through bi-directional referral systems

and coordinated marketing ○ Upkeep and expand on-line tools such as Compass (Partner Portal) ○ UAP, LWC and partners continually evaluate workshop demand, leader


28Co

nclu

sion

Conclusion

Moving into its 17th year, the UAP is in a solid position to fulfill the mission of making Living Well and other evidence-based self-management programs a standard practice in treating chronic conditions throughout Utah. Much of the delivery infrastructure is already in place; we have over 20 partners actively implementing Living Well, have seen stable reach patterns, are able to maintain fidelity, and are pursuing promising alternative funding sources. Even more exciting is the current shift in medical care, moving from a fee-for-service model to one focused on value-based care. Living Well capitalizes on this shift by showing to both improved health outcomes and an ability to help mitigate costs. While the UAP has many promising opportunities, the next five years are crucial for the viability of Living Well. Decreasing governmental support has already placed a strain on our delivery system and healthcare provider buy-in remains elusive. This strategic plan examined our business practices and laid out two potential scenarios with implementation steps based on each. Despite funding uncertainties that the future portrays, the long term sustainability of Living Well looks positive. Through the dedicated efforts of the UAP, our partners, funders, and countless others, we have hope that any Utahn faced with chronic conditions will have access to life improving, evidence-based, self-management education.

29Appendix A

Appendix A: Prevalence of Arthritis in Utah

Prevalence of Arthritis by Utah Small Areas: As one example of the burden of Chronic Dis-ease in Utah; the prevalence of arthritis in Utah’s Small Areas ranged from a low of 9.1 percent in Provo (South) to a high of 33.4 percent in Carbon/Emery Counties. Source: 2014 Arthritis Burden Report, 2014 Utah BRFSS.

Small Area Percent-age with Arthritis

Statistical Significance Compared to the State

Rate

Small Area Percentage with Arthri-

tis

Statistical Significance

Compared to the State Rate

State Total 20.1 Springville/Spanish Fork

21.0 -

Provo (South) 9.1 Lower South Ogden 21.1 -West Jordan (West)/

Copperton 10.9 Lower

Cache County (Other)/

Rich County (All) 21.2

-

SLC (Glendale) 12.8 - Roy/Hooper 21.2 -Orem (West) 13.0 - American Fork/Alpine 21.3 -Logan 13.4 Lower Orem (East) 21.4 -SLC (Foothill/U of U) 14.1 - Grand/San Juan Coun-

ties21.6 -

Pleasant Grove/Lindon 14.2 Lower West Jordan (Southeast) 21.7 -Provo North (BYU) 14.2 - Ben Lomond 22.2 -Midvale 14.3 - Ogden (Downtown) 22.8 -Riverton/Draper 15.3 Lower Southwest LHD (Other) 22.9 -West Jordan (Northeast)V2

15.3 - Cedar City 23.9 -

Lehi/Cedar Valley 16.1 - Box Elder Co. (Other) 24.0 -West Valley (West) 16.4 - Farmington/Centerville 24.0 -Summit County 16.8 - Washington Co. (Other) 24.0 -Clearfield/ Hill AFB 17.1 - Tooele County 24.2 -Millcreek 17.2 - St. George 24.2 -South Jordan 17.5 - Cottonwood 24.5 -

South Salt Lake 17.6 -

Taylorsville (East)/

Murray (West) 24.5 -SLC (Downtown) 17.7 - Utah County (South) 25.0 -

30Ap

pend

ix A

Small Area Percent-age with Arthritis

Statistical Significance Compared to the State

Rate

Small Area Percentage with Arthri-

tis

Statistical Significance Compared to the State Rate

SLC (Avenues) 18.2 -

West Valley East

Version 2 25.3

-

Syracuse/Kaysville 18.2 - Sandy (Northeast) 25.5 -

SLC (Rose Park) 18.2 -

Juab/Millard/Sanpete

Counties 26.0 HigherOrem (North) 18.8 - Taylorsville (West) 26.9 HigherMagna 19.6 - Bountiful 27.1 HigherSandy (SE) 19.6 - Holladay 27.5 Higher

Wasatch County 20.2 -

Woods Cross/

North Salt Lake 27.7 HigherTriCounty LHD 20.4 - Sandy (Center) 27.9 HigherKearns V2 20.6 - Riverdale 29.2 Higher

Layton 20.7 -

Sevier/Piute/Wayne

Counties 31.0 HigherMorgan County (All)/

Weber County (East) 20.8 -

Brigham City 31.8 Higher

Murray 20.9 - Carbon/Emery Coun-ties

33.4 Higher

Appendix A: Prevalence of Arthritis in Utah

31Appendix B

Appendix B: Active Implementation Partners

Area Agencies on Aging (AAA)• Five County Association of Governments• Salt Lake County Active Aging• Bear River Association of Governments

Center for Independent Living• Ability 1st Utah

Community Based Organization• Comunidades en Accion• National Tongan American Society

Healthcare Organization• Intermountain Healthcare• University of Utah Community Clinics• Utah Navajo Health System• Veteran Affairs Medical Center

Local Health Department• Tooele County Health Department (includes AAA)• Bear River Health Department• Central Utah Health Department• Davis County Health Department (includes AAA)• Utah County Health Department

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